American College of Surgeons trauma centre designation and mechanical ventilation outcomes Joseph J.DuBose * , Pedro G.R.Teixeira,Anthony Shiflett,Christine Trankiem,Bradley Putty, Gustavo Recinos, Kenji Inaba,Howard Belzberg Los Angeles County Hospital/University of Southern California School of Medicine, Los Angeles, CA,United States The association between hospital volume and outcomes has been examined by several investigators. 1,3,14,16,17,22 As increasing demands and diminishing resources threaten to further strain already burdened healthcare systems, 3,4,11,23 regionalisation of complex critical care services has increasingly been proposed as a possible solution. 3,4,15,23 The triage of patients with complex critical care needs to higher volume hospitals has several potential benefits. First, this modification of healthcare delivery may ensure that appropriate personnel and facilities are available and used most effectively for those patients in need of advanced resources. Additionally, regionalisation policies would provide health care professionals an opportunity to maintain critical proficiencies in the expertise required to care for this demanding and complex population. Patients requiring mechanical ventilation comprise a large component of the ICU population, and one that may benefit Injury, Int. J. Care Injured 40 (2009) 708–712 A R T I C L E I N F O Article history: Accepted 26 September 2008 Keywords: Trauma Trauma volume Mechanical ventilation Outcomes Mortality Pneumonia ARDS Critical care A B S T R A C T Objective: The association between hospital volume and outcomes following mechanical ventilation has been previously examined in diverse patient populations.The American College of Surgeons (ACS) Committee on Trauma has outlined criteria for trauma centre level designations with specific requirements for both specialty capabilities and hospital volume. Our objective is to determine the relationship between ACS centre designation and outcomes for trauma patients undergoing mechanical ventilation. Methods: We conducted a retrospective cohort study using the NationalTrauma Databank (NTDB), identifying 13,933 adult (age 18) trauma patients receiving mechanical ventilation for greater than 48 h from 2000 to 2004 who were admitted to either an ACS Level I or Level II trauma centre. The primary endpoints examined were mortality,pneumonia and Acute Respiratory Distress Syndrome (ARDS). Univariate analysis defined differences between those patients admitted to ACS Level I and Level II facilities.Logistic regression analysis was used to identify if ACS level designation was an independent risk factor for the goal outcomes. Results: Patients admitted to a Level I facility and mechanically ventilated for greater than 48 h were more commonly greater than age 55 (71.3% vs. 67.9%, p < 0.01), hypotensive (SBP < 90) (16.1% vs. 12.8 p < 0.01), and likely to have sustained injury due to penetrating mechanism (11.1% vs. 5.1%, p < 0.01). On univariate analysis, mortality and the incidence of pneumonia did not differ between the two groups. Level I admission was, however, less commonly associated with the development of ARDS (5.8% vs. 7.7%, p < 0.01) and patients admitted to Level I facilities were significantly more likely to be discharged to home than Level II counterparts (29.7% vs. 22.9%, p < 0.01). Logistic regression revealed that, while ACS Level designation was not a predictive factor for mortality or the development of pneumonia, admission to an ACS Level II facility was an independent predictor for the development of ARDS [ p < 0.01, odds ratio, 95% CI: 1.35 (1.18–1.59)]. Conclusion: For trauma patients requiring mechanical ventilation for >48 h, ACS trauma centre designation had no effect on overallmortality or the incidence of pneumonia.Compared to LevelI counterparts,however,patients admitted to an ACS Level II facility were significantly more likely to develop ARDS following trauma. This finding needs further investigation in a large, prospective analysis. ß 2009 Published by Elsevier Ltd. * Corresponding author at: University of Southern California, 1200 North State Street,Room 10-750,Los Angeles, CA 9003-4525,United States. Tel.: +1 323 226 8112; fax: +1 323 226 8116. E-mail address: jdubose@surgery.usc.edu (J.J. DuBose). Contents lists available at ScienceDirect Injury j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i n j u r y 0020–1383/$ – see front matter ß 2009 Published by Elsevier Ltd. doi:10.1016/j.injury.2008.09.015